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Variation in US Hospital Mortality Rates for Patients Admitted With COVID-19 During the First 6 Months of the Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Are hospital outcomes for patients with coronavirus disease 2019 (COVID-19) improving?

Findings  In this cohort study of 38 517 adults who were admitted with COVID-19 to 955 US hospitals, rates of 30-day mortality or referral to hospice varied from 9.06% to 15.65% in the best- and worst-performing quintiles. In the early months of the pandemic, 94% of hospitals in a subset of 398 improved by at least 25%, and the strongest determinant of improvements in hospital-level outcome was a decline in community rates of infection.

Meaning  All else being equal, COVID-19 mortality in hospitals seems to be lower when the prevalence of COVID-19 in their surrounding communities is lower.


Importance  It is unknown how much the mortality of patients with coronavirus disease 2019 (COVID-19) depends on the hospital that cares for them, and whether COVID-19 hospital mortality rates are improving.

Objective  To identify variation in COVID-19 mortality rates and how those rates have changed over the first months of the pandemic.

Design, Setting, and Participants  This cohort study assessed 38 517 adults who were admitted with COVID-19 to 955 US hospitals from January 1, 2020, to June 30, 2020, and a subset of 27 801 adults (72.2%) who were admitted to 398 of these hospitals that treated at least 10 patients with COVID-19 during 2 periods (January 1 to April 30, 2020, and May 1 to June 30, 2020).

Exposures  Hospital characteristics, including size, the number of intensive care unit beds, academic and profit status, hospital setting, and regional characteristics, including COVID-19 case burden.

Main Outcomes and Measures  The primary outcome was the hospital’s risk-standardized event rate (RSER) of 30-day in-hospital mortality or referral to hospice adjusted for patient-level characteristics, including demographic data, comorbidities, community or nursing facility admission source, and time since January 1, 2020. We examined whether hospital characteristics were associated with RSERs or their change over time.

Results  The mean (SD) age among participants (18 888 men [49.0%]) was 70.2 (15.5) years. The mean (SD) hospital-level RSER for the 955 hospitals was 11.8% (2.5%). The mean RSER in the worst-performing quintile of hospitals was 15.65% compared with 9.06% in the best-performing quintile (absolute difference, 6.59 percentage points; 95% CI, 6.38%-6.80%; P < .001). Mean RSERs in all but 1 of the 398 hospitals improved; 376 (94%) improved by at least 25%. The overall mean (SD) RSER declined from 16.6% (4.0%) to 9.3% (2.1%). The absolute difference in rates of mortality or referral to hospice between the worst- and best-performing quintiles of hospitals decreased from 10.54 percentage points (95% CI, 10.03%-11.05%; P < .001) to 5.59 percentage points (95% CI, 5.33%-5.86%; P < .001). Higher county-level COVID-19 case rates were associated with worse RSERs, and case rate declines were associated with improvement in RSERs.

Conclusions and Relevance  Over the first months of the pandemic, COVID-19 mortality rates in this cohort of US hospitals declined. Hospitals did better when the prevalence of COVID-19 in their surrounding communities was lower.

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Article Information

Accepted for Publication: November 14, 2020.

Published Online: December 22, 2020. doi:10.1001/jamainternmed.2020.8193

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Asch DA et al. JAMA Internal Medicine.

Corresponding Author: David A. Asch, MD, Center for Health Care Innovation, 3400 Civic Center Blvd, PCAM South Tower 14-171, Philadelphia, PA 19104 (asch@wharton.upenn.edu).

Author Contributions: Dr Islam and Mr Buresh had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sheils, Islam, Werner, Buresh, Chen.

Supervision: Sheils, Werner, Doshi.

Conflict of Interest Disclosures: Dr Doshi reported personal fees from AbbVie, Boehringer Ingelheim, Janssen, Kite Pharma, and Merck and grants from AbbVie, Janssen, Novartis, Merck, Pfizer, PhRMA, Regeneron, and Sanofi and outside the submitted work. No other disclosures were reported.

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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